Application for Housing

APPLICATION FOR HOUSING

BRUCE COUNTY COMMUNITY HOUSING REGISTRY P.O. Box 1450, 529 Gary Street Kincardine, Ontario N2Z 2Z4 Toll free number: 1-800-265-3022 Fax: 519-396-3499 E-mail address: [email protected]

Eligibility Requirements

• You must be a Canadian Citizen, Landed Immigrant (permanent residents) or have Refugee Claimant Status • At least one member of the household must be 16 years of age or older • You must not owe arrears to any community housing provider in Ontario • If you own a home, you must agree to sell it within six months upon offer of housing • You must be able to live independently

Application Checklist

 Please PRINT all information in ink

 Provide verification of Canadian Citizenship (photocopy of birth certificate or valid passport). If not born in Canada, provide proof of permanent residency in Canada. Example: Landed Immigrant papers, refugee claimant papers, citizenship card, etc.)

 All applicants 16 years of age or older must read and sign the Declaration and Consent on page 8

 If you have children listed on the application and have joint custody, provide a copy of a custody agreement

 If you owe rent arrears to another Community Housing provider and have a payment plan, please provide a copy of the agreement

 It is your responsibility to notify our office of any changes in information you have provided in this application within 10 business days.

***IMPORTANT: APPLICANTS WILL HAVE ONE (1) REFUSAL OF AN OFFER FOR HOUSING. IF YOU REFUSE A UNIT AT A BUILDING YOU HAVE SELECTED, YOUR NAME WILL BE REMOVED FROM THE WAITLIST.

Applications submitted incomplete or without the requested documents will not be processed.

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Section 1 – Applicant Information

Primary Applicant

______/_____/_____ Last Name First Name Social Insurance Number (optional) Date of Birth M ______D ______Y ______Male_____ Female_____

______Address Apt. No. City/Town Postal Code Home phone (____) ______Cell (____) ______Can we safely contact you at this address and phone  Yes  No number? If No, where can we contact you? E-mail Address:______

Preferred method of communication: Home phone Cell Email

Status in Canada (check one):  Canadian Citizen  Landed Immigrant  Refugee Claimant  Other (Please specify):

Co-Applicant

______/_____/_____ Last Name First Name Social Insurance Number Date of Birth M ______D ______Y ______Male_____ Female_____ Relationship to Primary Applicant: ______

Leave section below blank if same as Primary Applicant

LIST ALL OTHER PERSONS TO LIVE IN ACCOMMODATION APPLIED FOR:

Birth Date Sex Last Name First Name Relationship to Social Insurance M/D/Y M or F Primary Applicant Number

Is an additional child expected (baby, adoption, etc.) ( ) Yes ( ) No If yes, date expected ______. Page 2 of 8 Persons to contact in your absence Name Relationship Telephone Number 1. 2.

Section 2 – Present Accommodation and Previous Tenancy

Present Accommodation: Own Rent Temporary Staying with friends or family Co-Own

Please leave section below blank if you are not renting your current accommodations. Current Landlord Information Name Address City Postal Code Province Telephone Number Length of Tenancy (Years/Months)

List all previous addresses including when you lived there and the Landlord’s name and number: 1. Address: City/Town: Occupancy Dates: Subsidized? TO: Month Year Month Year  Yes  No Landlord Name: Landlord Address: Landlord Telephone ( ) ______Do you presently owe arrears to this landlord?

2. Address: City/Town: Occupancy Dates: Subsidized? TO: Month Year Month Year  Yes  No Landlord Name: Landlord Address: Landlord Telephone ( ) ______Do you presently owe arrears to this landlord?

Have you ever lived in Social/Non-Profit Housing? Yes No

Where was it located? ______

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Section 3 – Income and Assets (Detailed Statement of Monthly Income and Assets)

INCOME INFORMATION:

You are required to report on all sources of income that you and members of your household receive. This means all the money you receive, from all places.

GROSS MONTHLY INCOME Statement of Income Applicant #1 Applicant #2 Others on Application Ontario Works $ $ $ Ontario Disability Support Program Employment Income Employment Insurance (EI) Pensions (CPP, OAS, WSIB) Support Payments Other Income: (please specify) ______Total Income $ $ $

ASSET INFORMATION:

ASSETS are valuable things that you own. Below are a list of the assets that must be declared. VALUE OF ASSETS Statement of Assets: Applicant #1 Applicant #2 Others on Application Bank, Trust Company, Credit Union, other $ $ $ accounts (savings and chequing) Stocks, Bonds, GIC’s, Debentures and other securities/savings certificates RRSP Business Assets (eg. Partnership, self- employment, franchise, etc.) Monies owed to you or other persons listed on application Assets transferred (if you or any other person listed on this application have transferred assets within the last 36 months, please specify) Net value of Real Estate presently owned (eg. house, cottage, mobile home, land etc.) Other assets (specify) Total Assets $ $ $

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Section 4 – Housing Preferences

Unit Size:  Bachelor  1 Bedroom  2 Bedroom

3 Bedroom 4 Bedroom Other

Community Type:  Senior (60 years of age  Adult (16 years of age  Family (Adult(s) with or older) or older) dependent(s)) Types of Rent: Rent Geared to Income- Your rent is subsidized and is based on approximately 30% of your gross monthly income. Market Rent- You will pay full rent based on current market rates.

Affordable- Your rent is below Market Rent, and is NOT Rent Geared to Income, which means that your rent will not go down if your incomes goes down.

Housing Types: Social Housing (SH) – types of rent are Rent Geared to Income and Market Rent.

Non-Profit Housing (NPH) – private groups own and manage non-profit housing. Types of rent are Rent Geared to Income and Market Rent.

Rent Supplement (RS) – for rent supplement units, the County pays private sector landlords a portion of the rent. Types of rent are Rent Geared to Income at 30% or a maximum flat rate subsidy.

Affordable Housing (AH) –landlords have apartments that they rent at a rate determined below the Average Market Rent for Bruce County. To qualify for an Affordable Housing unit, your income must be below a certain level (please contact office for more information regarding this income level). The type of rent is Affordable.

Canada-Ontario Housing Benefit (COHB – a portable housing benefit allowance that is tied to the household

Project Type: I / We want to live in the following type of Housing:

 Subsidized Social Housing (Social Housing & Non-Profit Housing)  Private Sector Housing with Subsidy (Rent Supplement) I have a suitable unit (In-Situ)

 Affordable

Special Priority (This pertains to all members listed on the application)  I am applying for special priority status because I am currently living with a person who is abusing me, and I intend to separate permanently.  I have lived apart from the abuser for less than 3 months.  I am applying for special priority status because I am a victim of human trafficking.

If applying for Special Priority, please 1-800-265-3022 to obtain additional required forms.

Accessibility: I require/We require a modified/ wheelchair accessible unit  Wheelchair  Modified Please specify: ______ Other Please specify: ______

On the next page please select the buildings of your choice, you may select all areas that are applicable to your Unit Size (# of bedrooms required) AND Community Type (Adult, Senior, Family)

Housing Addresses Adult Senior Modified/ Elevator Unit Size Building Housing 16 yrs & Only Family Accessible Or Lift # of Design Type Circle your building choices up 60+ Bedrooms

CHESLEY - Municipality of Arran-Elderslie 59 – 4th Street SE X X 1 2 storeys RGI 81 – 2nd Street SE X Bachelor & 1 2 storeys RGI 83 – 2nd Street SE X X 1 2 storeys RGI PAISLEY - Municipality of Arran-Elderslie 286 Albert Street X X 1 & 2 2 storeys RGI/MKT TARA - Municipality of Arran-Elderslie 52 Maria Street X X X 1 & 2 2 storeys RGI/MKT WALKERTON - Municipality of Brockton 308 John Street X X 1 2 storeys RGI Mary/McNab Street X 3 & 4 Townhouse RGI 401 Cayley Street X X X 1 & 2 3 storeys RGI/MKT 920 Old Durham Road X X X 1,2,3 & 4 Townhouse RGI RIPLEY - Township of Huron Kinloss 50 Park Street X 1 2 storeys RGI LUCKNOW - Township of Huron Kinloss 535 Walter Street X 1 2 storeys RGI 550 Willoughby Street X X 1 & 2 1 storey RGI/MKT KINCARDINE - Municipality of Kincardine 1065 Huron Terrace X X 1 2 storeys RGI 915 Huron Terrace X X X 1 2 storeys RGI 529 Gary Street X X X X 1, 2 & 3 3 storeys RGI/MKT/AH Kincardine Townhouses X 2 & 3 Townhouse RGI Russell Meadows 755 X X X 1,2,3 & 4 Townhouse NPH Campbell St TOBERMORY - Municipality of Northern Bruce Peninsula 7432 Hwy #6 X X 1 & 2 1 storey RGI/MKT PORT ELGIN – Town of Saugeen Shores 647-659 Arlington Street X X 1 2 storeys RGI 510 Wellington Street X X X 1 2 storeys RGI 757 Wellington Street X X X 1 & 2 2 storeys AH 711-739 Wellington Street X X 3 & 4 Townhouse RGI 539 Ivings Drive X X X 1,2,3 & 4 Townhouse RGI SOUTHAMPTON - Town of Saugeen Shores 116 Albert Street X X 1 2 storeys RGI TEESWATER - Municipality of South Bruce 22 James Street X 1 1 storey RGI 5 Railway Street X X 1 & 2 1 storey RGI/MKT FORMOSA - Municipality of South Bruce Valley View Terrace 41 John X X 1 & 2 1 storey NPH Street MILDMAY - Municipality of South Bruce 4 Adam Street X 1 1 storey RGI WIARTON - Town of South Bruce Peninsula 295 Frank Street X 1 3 storeys RGI 621 Mary Street X X X 1 & 2 2 storeys RGI Miracle Place X X X 1, 2 & 3 Townhouse RS

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Section 5 – Declaration and Consent

Personal Information 1. I understand that there are laws that allow the Service Manager (or its delegate) to collect personal information about me. 2. I understand that the Service Manager (or their delegate) will use the information I give them to see if I qualify for the housing I have applied for; to see if I continue to qualify for rent-geared to-to-income assistance and to see how much assistance I am eligible for. 3. I allow the Service Manager (or its delegate) to give the information on this form and any attachment to the social services offices, other municipal service managers, district social services administration boards, or housing providers, without further notice to me, if the information is necessary for the purpose of making decisions or verifying eligibility for assistance under the Housing Services Act, the Ontario Works Act, 1997, the Ontario Disability Support Program Act, 1997, or the Day Nurseries Act. 4. I allow the Service Manager (or its delegate) to give this information on this form and any attachments to the government of Canada, a department, ministry, or agency of it, without further notice to me if the information is necessary of administering or enforcing the Income Tax Act (Canada) or the Immigration Act. 5. I allow the Service Manager (or its delegate) to give this information on this form and any attachment to any government or body with whom the Service Manager (or its delegate) has made an agreement under the Housing Services Act, without further notice to me, for the purpose of conducting research relating to a social benefit program or social housing or rent-geared-to- income assistance program. 6. I allow the Service Manager (or its delegate) to disclose and collect personal information about me from the following parties: person to contact in my absence; relevant agencies; credit bureaus and or other businesses, rent supplement landlords and individuals that provide credit or rental information to determine my eligibility. 7. I understand that any information on this form and any attachment given by the Service Manager (or its delegate) or private landlords to body listed above is confidential and will only be given in accordance with the Housing Services Act and associated regulations. 8. I understand that if I have any questions about the collection and use of personal information, I may contact the Coordinated Access and Social Housing office at 325 Lambton Street, P. O. Box 1450, Kincardine, ON N2Z 2Z4, 519-396-3450 ext. 104.

Declaration 9. I give my word that everything I have written in this application is correct and complete. 10. I understand that all information I give to the Service Manager (or its delegate) will belong to them and they will give my information to the housing providers I have chosen. 11. If something on this application is incorrect or not true, the Service Manager (or its delegate) or the housing providers I have applied to may request additional information, may cancel my application or both and I may be prohibited from re-applying for assistance for a minimum period of two years under the Housing Services Act 12. I understand that only the people I have listed on this application form may live with me in subsidized housing. 13. I understand that the Service Manager (or its delegate) will use the information I give them to see if I qualify for the housing I have applied for, to see if I continue to qualify for rent-geared-to-income assistance and to see how much assistance I am eligible for. 14. I give my word that I am in Canada legally. 15. Before I can be offered housing, I understand that I must pay back, or make arrangements, that are satisfactory to the Service Manager (or its delegate), to pay any arrears I owe with respect to any subsidized housing project.

ADDITIONAL REQUIREMENTS (optional) – Please provide us with any information you would like us to know in relation to your application:

I authorize and agree that the Service Manager (Bruce County Community Housing Registry) may collect, use, retain and disclose my personal information for the purpose of verifying my initial and/or on-going eligibility. This information is collected under the legal authority of the Municipal Freedom of Information and Protection of Privacy Act.

Applicant #1 Witness Date

Applicant #2 Witness Date

Direct questions about this application to 1-800-265-3022

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